Blood Pressure: Orthostatic (Ambulatory) - CE/NCPD

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OVERVIEW

Orthostatic vital signs (also known as postural vital signs) are measured with the patient in different positions to look for orthostatic changes. Orthostatic hypotension (OH) is primarily diagnosed by measuring blood pressure (BP) when moving from a lying down to a standing position. Changes in BP when moving from a sitting to a standing position can also be used to detect OH, although the supine-to-standing transition is generally considered more sensitive. While a drop in BP when moving from supine to sitting is possible, it's less commonly used for an OH diagnosis. In assessing patients for OH, BP changes going from supine to standing are more sensitive than going from sitting to standing.^{undefined#ref2">2}

Orthostatic vital sign measurement is used for noninvasive evaluation of fluid loss from conditions such as vomiting, diarrhea, diaphoresis, bleeding, abdominal pain, and blunt abdominal or chest trauma.⁶ Other indications for obtaining orthostatic vital signs include unexplained fainting, weakness or dizziness, and falls.⁶ OH is impacted by increasing age, a diagnosis of hypertension, and concurrent use of multiple medications (e.g., antihypertensive medications, diuretics, alpha blockers, nitrates, calcium channel blockers, antidepressants).^1,3,6

The use of orthostatic vital signs is disputed because there is no universal method on how to do them or what BP and pulse changes indicate “positive orthostatics.” Orthostatic vital sign measurements should be reviewed while also looking at the patient’s other symptoms (e.g., dizziness, lightheadedness, fatigue, visual dimming, shoulder pain).^2,6 These symptoms may become worse in hot environments and in patients who tend to stand still without changing position. Signs and symptoms of orthostatic changes are typically not present when the patient is supine but usually occur when moving into the standing position and can be quickly resolved by sitting or lying down.⁶

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Ask the patient to report any feeling of dizziness or instability when changing positions, as applicable. If the patient feels dizzy or unstable, stop the vital sign measurements and help the patient to sit or lie down.
• Teach the patient the signs and symptoms of OH (e.g., dizziness, light-headedness, fatigue) and give instructions on when to seek additional care.
• Teach older adults and patients with postural symptoms about the importance of sitting for several minutes before getting out of bed and standing up slowly after sitting for an extended length of time.

PROCEDURE

1. Clean hands and put on appropriate personal protective equipment (PPE) based on the risk of exposure to body fluids or infection precautions.
2. Determine if the patient has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
3. Review the patient’s previous experience and knowledge of orthostatic vital signs and understanding of the care to be provided.
4. Review the patient’s medication history to look for medications that may cause OH.

   Rationale: Some commonly prescribed medications can affect the heart rate.¹ Drugs such as alpha blockers, beta blockers, tricyclic antidepressants, and antipsychotics have been associated with an increased finding of OH.¹ Further, angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers can cause autonomic nervous system insufficiency.⁴

5. Be sure that the patient is lying in a flat, supine position before taking the initial BP and pulse measurements.

   Rationale: The patient should be in a flat, supine position for the BP to even out to a baseline supine pressure.

   Prevent unreliable results by avoiding invasive or painful procedures during the measurement of orthostatic vital signs.

6. Measure the patient’s BP and pulse after the patient has been in the supine position for the necessary amount of time (e.g., 2 to 10 minutes) using an appropriate-size BP cuff.^3,4,5
7. Help the patient to stand up, as needed. If the patient is unable to stand for a BP measurement, help the patient to a sitting position.

   When moving the patient from supine to standing, ask another health care team member for help for patient safety. Do not take measurements if the patient becomes extremely dizzy and needs to lie down or experiences syncope.

8. Once standing (or sitting), in the same arm as the initial reading:^1,3,4,5,6
   1. Measure the BP at 1 minute.
   2. Make sure the patient remains standing between the readings and measure the BP again at 3 minutes.

      Rationale: BP and heart rate should be measured at 1 and 3 minutes to confirm the BP changes continue.^1,3,4,5,6

   3. Ask the patient about symptoms of weakness, dizziness, or visual dimming that may happen when changing positions. Observe for pale color and sweating.
9. Compare the BP and pulse results, as one or more of these findings may indicate positive orthostatics in adults:^4,6
   1. Decrease in systolic BP of 20 mm Hg or more
   2. Decrease in diastolic BP of 10 mm Hg or more
   3. Increase in heart rate of 20 beats per minute or more
   4. Decrease of 30 mm Hg (threshold for diagnosis in a patient who is hypertensive)⁵
   5. Symptoms of cerebral hypoperfusion (e.g., dizziness, fainting)
10. Assist the patient with returning to a supine or sitting position, as needed.

EXPECTED OUTCOMES

• Accurate measurement of BP and pulse with position changes

UNEXPECTED OUTCOMES

• Weakness, dizziness, fainting, or falls, which may be indicative of OH

DOCUMENTATION

• Vital signs measurements, including position in which measurements were taken (e.g., with patient lying down, sitting, or standing)
• Unexpected outcomes and related interventions
• Education

PEDIATRIC CONSIDERATIONS

OH occurs when a child sits or stands up suddenly. It is a common reason for a drop in BP, and the child’s body will typically correct to normal BP within a few seconds.

OLDER ADULT CONSIDERATIONS

• OH can be a common cause and a contributor to hospitalization in older adult patients.²
• There is an association between OH and problems with mental abilities like memory, attention, and thinking among older adults.²
• The rate of OH is increased in older people, especially in adults over 65 years old.²
• OH may cause up to 30% of all fainting episodes in older adults.²
• The physical examination of patients with dizziness, gait disturbance, and falls should include an assessment for OH. OH is an independent predictor of unexplained falls in older adults.²

REFERENCES

1. Bhanu, C. and others. (2021). Drug-induced orthostatic hypotension: A systematic review and meta-analysis of randomised controlled trials. PLOS Medicine, 18(11), e1003821. Retrieved June 5, 2025, from https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003821
2. Clinical Overview. (2024). Orthostatic hypotension. Retrieved June 5, 2025, from https://www.clinicalkey.com
3. Juraschek, S.P. and others. (2024). Orthostatic hypotension in adults with hypertension: A scientific statement from the American Heart Association. Hypertension, 81(3), e16-e30. doi:10.1161/HYP.0000000000000236
4. Lough, M.E. (2022). Chapter 12: Cardiovascular clinical assessment. In L.D. Urden, K.M. Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (9th ed., pp. 190-205). St. Louis: Elsevier.
5. Montgomery, J.B. (2025). Chapter 32: Hypotension. In T.M. Buttaro and others (Eds.), Primary care: Interprofessional collaborative practice (7th ed., pp. 243-247). St. Louis: Elsevier.
6. Witting, M.D. (2022). When and how to use orthostatic vital signs. Journal of Emergency Medicine, 63(3), 460-466. doi:10.1016/j.jemermed.2022.09.007

Clinical Review: Kerrie L. Chambers, MSN, RN, CNOR, CNS-CP(E)

Published: July 2025